Terra Sigillata

Okay, some people are smoking some bad dope.

Whilst helping the PharmKid get down to the car for school this morning, I came upon PharmGirl, MD, in a rage while sitting in front of her laptop. The object of her vitriol was a 17 April article in BusinessWeek entitled, “Are There Too Many Women Doctors?: As an MD shortage looms, female physicians and their flexible hours are taking some of the blame.” The article derives from a point/counterpoint pair of essays in the 5 April issue of BMJ (British Medical Journal) entitled, “Are there too many female medical graduates?” (“Yes” position, “No” position – free full text at the time of this posting)

While the BMJ essays primarily address issues in the UK, they are common to the US and many other countries – BusinessWeek’s Catherine Arnst describes the long-term problem that underlies concerns about too many women in medicine:

Various studies have projected a shortfall of anywhere from 50,000 to 100,000 physicians in the U.S. relative to demand by 2020, and the Institute of Medicine, a federal advisory body, just reported that in a mere three years senior citizens will be facing a health-care workforce that is “too small and woefully unprepared.”

One cannot deny these facts. But an argument has been made that the increased representation of women among medical graduates is increasing the number of physicians who work part-time or drop out of the physician pool altogether when having children.

“It’s pretty much an even bet that within a year or two of entering practice they will go on maternity leave,” says Phillip Miller, a vice-president of the medical recruiting firm Merritt, Hawkins & Associates. “Then they are going to want more flexible hours.”

Such demands tend to irritate older doctors. “The young women in our practice are always looking to get out of being on-call,” says a male internist at a large New York-area medical group who asked not to be named. “The rest of us have to pick up the slack. That really stirs up a lot of resentment.”

Arnst herself counters these anecdotal assertions with one of many advantages of increased numbers of women physicians:

On the plus side, women are willing to take on lower-paying specialties that male doctors are moving away from, such as primary care, pediatrics, and obstetrics. Since 1996 there has been a 40% jump in the number of women choosing primary care, offsetting the 16% decline in men entering the field.

Moreover, Arnst points out that the issue may be more one of all docs choosing to seize back more of their lives, rather than an issue of gender:

The issue of shorter work weeks may in fact be as much generational as gender-based. Newly minted male doctors are also rejecting the heroic 80-hour weeks put in by physicians of yesteryear.

I’m not a physician but I would submit that I have made changes in my own career to support the mission of my physician wife, an issue kindly brought to light by Canadian ER doc, Couz, on her excellent blog, Tales from the Emergency Room and Beyond:

In all seriousness, I wouldn’t have married me. My husband is a glutton for punishment.

Again, this may be anecdote, but an anonymous commenter on the long thread following the BusinessWeek article confirms my experience with most of PharmGirl’s female colleagues: they bust their asses to do their jobs despite biology and societal pressure to be doctors first and women second:

It is interesting that the statistics did not talk about female physicians who work full time similar to their male counterparts. I am a full time female physician who works long hours just like my male colleagues. I took only eight weeks for maternity leave twice during my career. I never entertained working part-time for economic and financial issues. But I always had to live with the guilt of not having enough time with my family and spending too much money for hiring nannies. Perhaps Dr. Nancy Oriol’s comments has to be taken wholeheartedly that there might be some issues with retention. We should consider alternative ways of making the discipline accommodating for the younger generation who have to juggle work and life balance.

Indeed. The closing point from the Harvard dean of students punctuates this discussion:

Ultimately, medicine will have to accommodate the lifestyle demands of a younger generation if it is to address the physician shortage, says Dr. Nancy Oriol, dean of students for Harvard Medical School. “If there is a problem with retention, it might serve us well to investigate details of the career paths themselves.”

Finally, I’m of the mind of commenter MDeducator who notes that we men, physicians or otherwise, need to sack up and support what is good about women in medicine:

It is pathetic and ludicrous to blame the physician shortage on female physicians. If it weren’t for them, flexibility would not exist in this career, and patients would be able to connect with us even less than they do now. The primary care shortage would also be far more pronounced than it is now. Until we adopt more human behaviors, such as the ones women have brought to our career, we will always have difficulty with malpractice lawsuits. Perhaps taking on some child care responsibilities as male physicians might do us some good. We may even be able to relate better to humanity??? as well as our patients.

I recognize that I’ve rambled on a bit here based mostly on the emotional and anecdotal aspects of this question. I’m still working my way through the references cited in the two BMJ essays but I see generally that there are conflicting data on whether women contribute more or less to the physician pool (i.e., they may take off nine months here and there but they have greater life expectancy and may work longer). Moreover, the glass ceiling for women in medicine may also mean that they stay in the working physician pool longer because the administrative ranks are often closed to them, as cited in the BMJ essay by Dr Jane Dacre, vice dean of University College London:

The Medical Schools Council report, published in June 2007 showed only 11% of the professorial staff in UK medical schools are women compared with 36% of clinical lecturers. The proportion of women decreases with increasing academic grade. A similar situation exists in the United States, where only 15% of full professors and 11% of department chairs are women.

In this context, regular readers may recall my take on a NEJM article by Nancy Andrews, MD, PhD, appointed in 2007 as the first female dean of a top 10 US college of medicine, where she is incredulous at the national and local response to her taking the helm:

…it continues to be true that we do not expect women to hold certain positions in society or medicine. Recently, I witnessed firsthand the persistence of such expectations, when my husband, our children, and I went to visit a school in North Carolina where Duke staff members had made an appointment for the family of the new dean of the medical school. As we entered the school, its principal vigorously shook my husband’s hand and welcomed him, saying, “You must be the man of the moment.” Unfortunately, it is quite understandable that it wouldn’t have crossed his mind that I might be the “woman of the moment” instead…

The bottom line is that several major medical societies agree that a physician shortage looms as baby boomers transition into being patients for the most medically-intensive stage of life. But to blame women physicians, even partly, for this problem is absolutely absurd. Women bring unique and necessary gifts to the practice of medicine and pursue specialty areas that men would rather not. Let’s give them appropriate credit and work on the real problems of society and the medical patriarchy in solving what might be a real issue of the retention of female physicians.

Note added in proof: I was reminded by his comment below that PalMD had a very thoughtful post on this topic on 13 April.

Comments

  1. #1 PalMD
    April 25, 2008

    These attitudes are pervasive in medicine. Strangely enough, I’ve never heard a patient complain. Hmmm….

  2. #2 Pen
    April 25, 2008

    Too many male ‘absent parents’ are ruining society! The only reason this looks like a gender-related problem is that males don’t pull their weight in the family.

  3. #3 student_b
    April 25, 2008

    Too many male ‘absent parents’ are ruining society! The only reason this looks like a gender-related problem is that males don’t pull their weight in the family.

    QFT.

    ‘Nuff said.

  4. #4 juniorprof
    April 25, 2008

    But to blame women physicians, even partly, for this problem is absolutely absurd. Women bring unique and necessary gifts to the practice of medicine and pursue specialty areas that men would rather not. Let’s give them appropriate credit and work on the real problems of society and the medical patriarchy in solving what might be a real issue of the retention of female physicians.

    Hit the nail on the head. Honestly, what is wrong with these people? In my view it is a problem that females in all professions do not get enough maternity leave. This is a serious problem that needs a real solution. Why waste time on absurd arguments that will clearly make the problem worse?

  5. #5 Becca
    April 25, 2008

    What the heck is wrong here?
    We have oodles and scads of students wanting to go into medicine. We have oodles and scads of PhD scientists who would be happy to teach them during the first couple of years. Why don’t we have enough doctors? Is there a bottleneck in clinical training? Is the problem not really “insufficient doctors” per se, but “insufficient doctors willing to go into ‘undesirable’ specialties or willing to practice in ‘undesirable’ areas?”

  6. #6 Kim
    April 25, 2008

    My dentist made a similar comment, when I said it was difficult to find a dentist in town. I’ve wondered whether medical and dental schools could train more students – I’ve had doctors who split a practice, and it has been wonderful. (I particularly like being able to get Mom Advice as well as medical advice from my general practitioner, especially when my son was a toddler. “No, it isn’t strep throat, and when my daughter bit while nursing, I did X…”) A full-time doctor would have been much less useful.

    And the women doctors in my town who have given up their practices were originally laid off by the largest provider in town. We had doctors, but the practice was losing money, so the company pulled out of town, and left the doctors unemployed. Some went into independent practice, but the hassle wasn’t worth it for some of them – my doctor has gone into organic farming full-time. I can’t blame her.

  7. #7 AnnR
    April 25, 2008

    I get health care from a place that hires the doctors.
    So they’ll reel off a list of who do you want to see when you call.

    I ALWAYS PICK A WOMAN.

    Part-time/flexible hours for a doctor are like part-time for a lawyer. That’s 40-50 hours a week instead of 60-80. We are talking about a week that many normal people consider a full week.

    My PCP is part-time. If I’ve sprained my ankle or have a sinus infection and want to see someone now then I see one of the PAs that work with her – usually today. If I have issues I can follow-up with her.

    I worked part-time (35 @ week) for many years in IT when my kids were little. I had to leave to pick them up so full-time with it’s unlimited overtime commitment wasn’t acceptable.

    I went back to full-time when they got older. So those lady doctors aren’t out forever, just for awhile. Our culture likes to discount middle-aged women, but the truth is – we’ve just gotten going. So I think medicine will survive!

  8. #8 Katharine
    April 25, 2008

    I’m not a physician (I’m an undergrad planning to get a PhD in neuroscience), but crap like this is what essentially cements my decision to not have a child. It interferes too much with research, and I prioritize research before family any day.

  9. #9 Dave Munger
    April 25, 2008

    Becca hit the nail the head. The problem is that we’re not training enough physicians. Male or female, we shouldn’t expect them to work 80 hours a week.

  10. #10 Barn Owl
    April 25, 2008

    We have oodles and scads of PhD scientists who would be happy to teach them during the first couple of years.

    This is certainly not true for the anatomical disciplines-gross anatomy, histology, embryology, neuroscience-in medical and dental schools. Most such schools in the US have experienced a shortage of PhDs willing/able to teach in these disciplines during the preclinical years of training. This shortage was described in a 2005 article in Academic Medicine, by R.S. McCuskey et al. (Vol. 80(4), 349-351).

    That being said, there is every reason to encourage pre-doctoral students and recent PhDs to consider a career that focuses on teaching anatomical sciences in medical and dental schools. If your background is in comparative vertebrate embryology, anatomy, and/or neuroscience, it’s a relatively easy transition to teaching these subjects in health professions courses. I know this from personal experience, and I can also say that it’s certainly not a bad way to make a living, as long as you can keep some research going on the side. You also gain a head start on recruiting students to do projects in your lab over the summer…they already know and trust you from slogging away in gross anatomy lab together.

  11. #11 MMW MD
    April 25, 2008

    The current projected MD shortage actually comes from a previously projected MD surplus, resulting in stricter limits in class size for American medical schools. These are limits that have more recently been relaxed in an attempt to blunt some of the possible gap in future supply and demand. Medical school admissions numbers are determined by politics. Keeping the number of doctors in check is meant to protect physician salaries by preventing a glut of supply. The reality is that, no matter what future shortages ensue, there is already a shortage in many parts of the country and a glut in other, academic centers mainly located in popular cities, where physician salaries are, as a result, typically lower. None of this has anything at all to do with gender, unless the desire of the old guard male docs to keep salaries inflated counts as a gender issue.

  12. #12 PalMD
    April 25, 2008

    Most of the shortage is in primary care. American physicians often have med school debt in the hundreds of thousands of dollars, and feel economically pressured to go into subspecialty fields.

    Unless we start subsidizing medical education and/or primary care, there will always be a shortage.

  13. #13 pulezze
    April 25, 2008

    It’s always easier to blame women than to have to take a long hard look at the fact that the system itself is built in a way that is both painful and unsustainable, especially for people juggling other burdens. Those other ‘people’ tend to be women for societal reasons, but not always. All you need is kids, or a caretaking role in the family, or a chronic illness, and you’re screwed in any discipline that holds the ability to work 80h weeks as the de facto standard for ‘productivity’.

  14. #14 steppen wolf
    April 25, 2008

    Men have been able to pull 80-hour weeks because their wives used to stay at home with the kids. But I expect that younger generations will require both genders to take more equal responsibilities in terms of family time, and this will require adjusting working hours for both females AND males.

    Just my five cents.

  15. #15 PennyBright
    April 25, 2008

    My family’s primary care MD is a woman — she’s great – I could ask for a better MD.

    What I could ask for is an MD who is available. :( We’re in a tough position right now, because we’ve got some on-going health issues that need regular physician oversight, and our MD is on leave. I can’t fault her at all — her baby came way earlier then babies should, and I can completely sympathize that she’s going through some tremendous challenges, and needs to focus her energy on her family right now.

    I just wish I didn’t have to choose between getting the medical care I need and maintaining a relationship with the MD I like best — I really wish she were in a shared practice or partnership instead of solo practice. And I’m worried that because she isn’t, this medical emergency in her family might drive her out of practice — and then we’re out a great GP.

  16. #16 drdrA
    April 25, 2008

    Just in reference to Juniorprofs comment- right now in the US there is no consistency or requirement for any paid maternity leave. You can take up to 12 weeks UNPAID- but that’s the extent of our maternity leave in this country. It is pathetic.

  17. #17 Drekab
    April 25, 2008

    Hmmm, there’s not enough doctors anymore… I know let’s fire half of them, that should solve the problem.
    Brilliant!!!

  18. #18 clinteas
    April 26, 2008

    Male Emergency Physician myself,can i just say that the female doctors I have worked with are either already pregnant and use that as an excuse to lie down half of the shift,or see less patients,or take frequent sick leave,or become pregnant within a year or two,and taking on a well-paid position just prior to falling pregnant serves them as a welcome finance boost.
    If you want to be equal to your male counterparts in your job,be prepared to put in the same effort.If you want to be a mother,be a mother.

  19. #19 Azkyroth
    April 26, 2008

    Clinteas, is there any chance you’ll address some of the arguments brought up here instead of just throwing around shallow, self-righteous antiplatitudes as if every problem could be solved with a simple (in every sense of the word) slogan that fits on a bumper sticker?

  20. #20 Abel Pharmboy
    April 26, 2008

    Clinteas, I can certainly understand your apparent frustration given the demands of your practice setting but, as Azkyroth points out, your comment perpetuates the problem and makes no attempt to offer solutions that could improve your work environment. You’ve really got to be out of your mind to think that women “use” their pregnancy to slack during shifts or manipulate their employment for financial gain – your statement makes it clear that you have not spent any considerable time discussing these issues with your female colleagues.

    Rather than rant, blame, and throw out unsubstantiated claims of motive for your fellow ER physicians, perhaps you might channel such energy into working with your administration to make accommodations for the workload impact of basic human physiology that may have been lost on you during your training. If you’re really a physician and not a troll, I’m very disturbed about the future of medicine.

  21. #21 PhysioProf
    April 26, 2008

    If you want to be a mother,be a mother.

    If you want to be a father, be a father. Don’t be a fucking parasite on the labor of women to raise your children.

  22. #22 Dr. Free-Ride
    April 26, 2008

    PhysioProf for the win!

  23. #23 Joe
    April 26, 2008

    For some more discussion:
    http://www.sciencebasedmedicine.org/?p=87

  24. #24 PalMD
    April 26, 2008

    Clinteas:

    What PP said.

    Also, perhaps you can take a look at your situation from several different perspectives.

    If you feel overworked, perhaps it is not the fault of a single female physician, who may also feel overworked, but of the way your ER has set up its practice model. There is always a balance between work and compensation, and if you wish to work a little less, you may have to hire another doc and everyone gives up a sliver of their salary to support the position.

    If you ever become ill, I doubt that your female colleague will bitch and moan about what a shirker you are. If you’re lucky. Payback’s a bitch.

  25. #25 Joe
    April 26, 2008

    Wherever contact with the public is involved (medicine, law, legislators) I want to see diversity. With respect to medicine, I recall reading medical journals in the 70s, when they were coming to grips with lack of diversity. I read about gynecologists who told women who found sex painful, that they just had to live with it; and GPs who set about suturing wounds thinking their “negro” patients did not need anesthesia.

    (When I was young, a friend had an argument with his wife; his father said “maybe you need to slap her a bit;” he did not. Decades later, a co-worker abused his wife and the police put him out on the street. I attribute the change in climate for domestic abuse to the increased number of women practicing law.)

    As for the reduced hours some women MDs work- med schools sometimes admit older students who will miss years, not mere hours. They also produce MD/PhDs who miss years, and then work reduced hours (sorry, Orac). If there is going to be a shortage of MDs, there are smarter ways of dealing with the problem than excluding women.

    I would rather be treated by a well-qualified doctor (male, female or Republican) than one who got into med-school merely because of a preference against women.

  26. #26 AB
    April 27, 2008

    Pal MD brings up a good point. The shortage seems to be in primary care. After medical school and debt often reaching hundreds of thousands of dollars, life as a GP sounds much less appealing than life in a sub-specialty field where loans can be repayed more quickly. This shortage is what seems to be the real problem and has NOTHING to do with gender!

  27. #27 MMOToole
    April 28, 2008

    I hate to tell colleagues like clinteas and co., but…

    Their “model” of medical practice is going bye-bye fast, and it’s got nothing to do with “women in medicine”. Every residency program I know (and I’m clinical faculty at one) is limiting the number of hours in the week and the number of consecutive hours its residents can work, and for good reasons. Much as I decry the necessity (and I’m one of those women who is working 80 hrs/week or more, before you characterize me as “another slacker woman”), there are numerous cases of serious medical mistakes made by overtired doctors, in residency and out. There are several studies which show that lack of sleep contributes to poor judgment. Coffee and food only compensate so far, and non-sleeping downtime is also essential for mental focus, not to mention continuing medical education.

    Most of today’s residents—male and female—are learning to practice in a world where they’re not expected to be “on-call” for more than 18 or 24 hours at a stretch, and with much longer stretches of free/sleep time in between. Male residents are also demanding more personal time. In fact, the various Councils on Resident Education, the Professional Colleges, and the state legislatures are requiring and mandating limitations to resident work hours. This isn’t The House of God any more, gentlemen (since it seems to be the men, and the men in the “macho” surgical specialties at that, who complain the most about “too many women”). There is also less stigma about getting professional psychological help; are you going to characterize all doctors who actually see a shrink as “wimps” who need to learn to “suck it up”?

    Medicine overall is changing in the same direction. Whether that is a good thing or not, only time will tell. It might, however, decrease the abysmal divorce rate among physicians, as well as the very real problems of addiction and impairment.

    I think you’ll find, oh macho males, if you look at the whole picture and not just “in-hospital” time, that women in medicine are faced with the same “3 full-time jobs” as women everywhere. I would venture to guess that many of the men I know in medicine would be unable to survive without the full-time logistical support (cleaning, cooking, child care, laundry) “provided” by the women in their lives…and the realities of medical economics these days means we can’t all afford the full-time help doctors’ families of previous generations had.

    Sadly, I’ve been hearing this same BS since I was in medical school 30 years ago. It utterly ignores the number of men who “never practice” clinical medicine because they’re in pure research, or end up as administrators in hospitals, medical schools, or insurance plans, or lose their licenses because of impairment, or do something completely different (like a JD on top of the MD). They, too, could be considered “dead weight” in a medical school class. I would rather have two competent, well-rested and well-adjusted women working 36-40 hours apiece than one overworked, over-tired, and psychologically screwed up 80 hour a week “ironman”.

  28. #28 per
    May 11, 2008

    surprised that you have misrepresented McKinstry’s argument. He explicitly starts from the premise that men and women should be equally represented at medical school, on the basis of equal opportunities. In the UK, it is edging 60% female.

    When there were more men than women at Medical school, it was institutionalised sexism. Now there is a preponderance of women. You haven’t engaged with this issue at all.

    If ever you read the references, and come to a view on whether there is a sex difference in working life, do let us know. A 10% difference in the number of medic years available can have a large effect on patient care when the system is stretched.

    per